Provider Demographics
NPI:1346200920
Name:CONEMAUGH VALLEY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CONEMAUGH VALLEY MEMORIAL HOSPITAL
Other - Org Name:MEMORIAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEFASQUALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-534-5031
Mailing Address - Street 1:551 MAIN ST 3RD FLOOR ATTN NICOLLE
Mailing Address - Street 2:THE INFORMEDX GROUP
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901
Mailing Address - Country:US
Mailing Address - Phone:814-539-5724
Mailing Address - Fax:814-536-7092
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:CONEMAUGH EMERGENCY PHYSICIANS GROUP
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-534-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007568490046Medicaid
PA1007568490046Medicaid